Surgery (4)

Question 1

Definition of hernia

Answer 1

A protrusion of the whole or a part of a viscus from its normal position through an opening in the wall of its containing cavity

Question 2

Difference between direct and indirect hernia

Answer 2

Direct:

• due to a weakness in the posterior wall of the transversalis fascia
• emerge in Hesselbach’s triangle
• do not extend to the scrotum

Indirect:

• usually stop at the superficial ring
• do not emerge in Hesselbach’s triangle

Question 3

Where is inguinal canal located?

Answer 3

Question 4

Anatomy of inguinal canal

Answer 4

Question 5

Where is inguinal and direct hernia located?

Answer 5

Question 6

Components of clinical examination for hernia

Answer 6

1) Check it’s a hernia

Smooth, reducible, cannot get above it, exhibits a cough reflex

2) Check Inguinal vs Femoral

Protrudes either above and medial to pubic tubercle (inguinal)

Protrudes below and lateral to the pubic tubercle (femoral)

3) Check whether its direct or indirect

Reduce the hernia, apply pressure of the deep inguinal ring, ask the patient

to cough/strain. If the hernia is controlled it is probably indirect but if it comes out it may be a direct hernia

Question 7

Content of spermatic cord

Answer 7

3 arteries

• Artery to vas deferens
• Testicular artery
• Cremasteric artery

3 nerves

• Ilioinguinal nerve (L1)
• Nerve to cremaster
• Autonomic nerves

3 other structures

• Vas deferens
• Pampiniform plexus
• Lymphatics

Question 8

What should you suspect in L sided varicocele?

Answer 8

Renal cell ca

left-sided varicocele (due to occlusion of left

testicular vein → drains directly into left renal vein

Question 9

Causes of mass in the groin in a man

Answer 9

• Inguinal hernia
• Inguinal lymph nodes
• Saphena varix (dilated varicose vein a the SFJ)
• Femoral artery aneurysm
• Varicocele
• Encysted hydrocele of the cord.
• Lipoma of the cord
• An incompletely descended testicle

Question 10

Where the majority of the renal cell ca arise from?

Answer 10

Majority arise from the proximal renal tubular epithelium

Question 11

The classical triad of renal cell carcinoma

Answer 11

• haematuria
• loin pain
• abdominal mass

Question 13

Possible endocrine effects of renal cell ca

Answer 13

Endocrine effects:

• EPO → polycythaemia
• PTH → ↑Ca2+
• renin → HTN
• ACTH → Cushing’s

Question 14

Management of renal cell ca

Answer 14

• Partial/total nephroectomy depending on tumour size
• tyrosine kinase inhibitors

• 25% have metastases at presentation,

Question 15

What’s that?

Answer 15

Cannonball mets in the lungs

• commonly from renal cell ca

Question 17

(3) types of bladder cancer

Answer 17

• Usually transitional cell carcinoma
• Rarely squamous cell (if schistosomiasis infection)
• adenocarcinoma (urachus remnant)

*urachus is a structure normally only present during development in the womb that connects the bellybutton and the bladder. This connection normally disappears before birth, but in some people remains

Question 18

Occupational exposure and bladder cancer

Answer 18

occupational exposure to chemicals:

• analine dyes
• aromatic amines

Question 19

The most common presentation of bladder cancer

Answer 19

painless haematuria

Question 20

Management of bladder cancer

Answer 20

• Cystocopy + endoscopic resection or diathermy
• Immunotherapy (BCG)
• Chemotherapy
• Radical cystectomy + radiotherapy

Question 21

(3) differentials + descriptions for testicular pain

Answer 21

Question 22

Components of peripheral vascular exam

Answer 22